Disabled Dependent Questionnaire

RI 30-10, Disabled Dependent Questionnaire

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3206-0179 can be found here:

Documents and Forms

Document Name Document Type
Form RI 30-10; Revised Disabled Dependent Questionnaire Form and Instruction
RI 30-10; Revised Disabled Dependent Questionnaire RI30-010_2010_06_MarkUp.pdf Form and Instruction
RI 30-10; Revised Disabled Dependent Questionnaire RI30-010_2016_04_MarkUp.pdf Form and Instruction
RI30-010_NonMaterial_Justification_2016.docx RI 30-10, Justification for Non-Material Change IC Document

Information Collection (IC) Details

IC Title:	Disabled Dependent Questionnaire	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 5 CFR Chp 1 Sect 843.406 - 843.410 (To search for a specific CFR, visit the Code of Federal Regulations.)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	RI 30-10; Revised June 2010	Disabled Dependent Questionnaire	RI30-010_2010_06_MarkUp.pdf		Yes	No	Fillable Printable
Form and Instruction	RI 30-10; Revised April 2016	Disabled Dependent Questionnaire	RI30-010_2016_04_MarkUp.pdf		Yes	No	Fillable Printable

Line of Business: General Government

Subfunction: Executive Functions

Privacy Act System of Records
Title: OPM/Central-1	FR Citation: 73 FR 15013

Number of Respondents: 2,500	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	2,500	2,500
Annual IC Time Burden (Hours)	2,500	2,500
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
RI 30-10, Justification for Non-Material Change	RI30-010_NonMaterial_Justification_2016.docx	03/31/2016

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.